Strong family support can help psoriasis patients manage their disease through better adherence to treatments while improving mental health.
Psoriasis is a chronic, painful, disfiguring and disabling disease for which there is no cure. An immune-mediated inflammatory skin disease, it causes itchy, red, and scaly patches on the skin, occurring most commonly on the elbows, knees, scalp and lower back.
Although it is a well-recognized condition, this disease is more than a physical affliction and greatly impacts the patient’s quality of life. Unlike in the past when it was only considered a skin disease, psoriasis is now considered a systemic disease, and is associated with psychological, metabolic, arthritic, and cardiovascular comorbidities.
Globally, psoriasis is estimated to affect about 2% to 3% of the population, or at least 60 million people. The prevalence of psoriasis varies widely across populations residing in different geographical locations. In adults, it ranges from 0.14% in East Asia to about 2% in Australasia and Europe, while in some Northern European countries it can reach 8% to 11%.
Among Southeast Asian countries, there are at least 40,000 patients living with psoriasis in Singapore, while in Malaysia, the number of individuals affected by psoriasis increased steadily from 0.27% to 0.51% between 2010 and 2020.
Although the prevalence of the disease in Asia tends to be lower compared to in Western countries, the impact may be even greater in Asia because of cultural reasons, socioeconomic status and higher levels of social stigma and discrimination due to misconceptions of the disease.
Psoriasis doesn’t look the same for everyone
According to Dr Tan Wooi Chiang, Consultant Dermatologist at Gleneagles Hospital in Penang and President of the Dermatological Society of Malaysia, “There are several forms of psoriasis, from the common plaque psoriasis, which constitutes 80% to 90% of cases, to the rare, severe forms of psoriasis such as generalized pustular psoriasis (GPP), which affects about 0.02% of the population in Malaysia.”
Dr Koh Hong Yi, Consultant Dermatologist at TSN Dermatology Skin Specialist Clinic, Singapore, elaborates, “Most physicians can easily recognize plaque psoriasis, one of the most common forms of psoriasis, but the less common forms of psoriasis have often been misdiagnosed. For example, it is common for physicians to mistake scalp psoriasis for severe seborrheic dermatitis, which looks like dandruff. Likewise, flexural psoriasis which mainly affects the folds of the skin in areas such as the armpit and groin is often mistaken for a fungal infection.”
Psoriasis affects more than just the skin; it takes a significant toll on both the physical and psychological well-being of patients. The physical impact comes from the formation of visible patches on the skin, which causes the constant itching and pain that can be severely uncomfortable. For patients with psoriatic arthritis, joint pain and swelling further compound the challenges. As well as the physical burden, the social stigma associated with visible skin conditions can often make patients feel isolated, ashamed, and self-conscious.
According to Dr Koh, “Psoriasis has a ripple effect on mental health. Many patients face depression or anxiety, which is often not acknowledged by those who are unfamiliar with the condition.”
The correlation between psoriasis and mental health issues is well-documented, with patients experiencing higher rates of anxiety and depression than the general population. Furthermore, patients with psoriasis report experiencing anger or helplessness, and present with a higher rate of suicidal ideation than patients with other conditions. A study revealed 9.7% of patients with psoriasis reported a wish to be dead and 5.5% reported active suicidal thoughts at the time of study.
Cultural beliefs in parts of Asia also contribute to the stigma, further impacting patients' social lives. Dr Koh observes, “The fear of stigmatisation and social isolation is especially acute in our younger patients. Adolescents often worry that the visible psoriasis on the skin would make their friends and peers less likely to accept them. Among adults, the main concern is being accepted by colleagues at work. A supervisor once asked my patient to cover up her psoriasis as they thought leaving it exposed may adversely affect her work.”
He adds, “There have also been cases where patients were turned away at swimming pools, gyms and hair salons, because others thought their psoriasis was contagious. It is not surprising then, for such individuals to avoid social gatherings because they feel embarrassed or fear negative reactions from others.”
Getting the right treatment is crucial
Addressing both the physical and mental dimensions of psoriasis is essential in managing the disease, as they are intertwined with, and impact a patient's quality of life.
Current treatments typically focus on managing symptoms, minimising flare-ups, and improving quality of life. Patients with mild to moderate disease can often be successfully treated with topical therapies such as steroids and vitamin D3 analogues, while those with more severe disease may require systemic therapies such as phototherapy, oral retinoids, immunosuppressants, and the latest innovation - biologics, which have been proven to be highly effective in managing the disease.
According to Dr Praneet Sajjachareonpong, Dermatologist at Bangkok’s Phyathai 2 Hospital in Thailand, “We have made strides in treating psoriasis thanks to Thailand’s universal health coverage, although access to advanced therapies like biologics remains limited for some patients. While we can obtain special approvals for patients who do not respond to other therapies to access biologics, the processes and paperwork that enable them to do so at subsidized rates can be time-consuming. Additionally, upon approval, this arrangement is only valid for six months, and thereafter the patient will either have to reapply for the special approval or continue paying for the drug at the regular price.”
Similarly in Malaysia, the main barrier for most psoriasis patients is the high cost of medications, especially for the latest generation of biologics. Dr Tan shares, “Currently, less than 2% of psoriatic patients in Malaysian public hospitals are receiving biologics, which have been proven to reduce disease severity and improve quality of life. When patients struggle to afford medication, they may also delay seeking follow-up care, further complicating disease management. Ensuring wider access to these treatments is critical to improving patient outcomes.”
Family support makes the difference
While treatment plays a fundamental role in managing psoriasis, the role of family support is invaluable in the management of disease.
Dr Koh remarks, “Support from family can make a tangible difference in a patient’s journey with psoriasis. Knowing they have a network of people who understand what they are going through can not only alleviate stress, but encourage treatment adherence. Patients who have supportive family members are more likely to stick with their treatment regimen, which is essential for managing the disease over the long term."
He elaborates, “Family members and caregivers can help patients apply topical medications particularly on hard-to-reach areas, inject medications, collect drugs from the pharmacy, or even accompany them for medical appointments. All these help patients alleviate their disease burden.”
Working together for patients' well-being
The road to getting the right diagnosis and appropriate treatment plan can be very long and taxing for individuals suffering from psoriasis. As reported by the World Health Organization (WHO), there is a general lack of healthcare professionals and, by extension, a lack of specialists in psoriatic disease. This results in reduced awareness about the disease and associated comorbidities among the healthcare community, increasing the likelihood of under-diagnosis and prescription of ineffective or unsuitable therapies.
It is imperative that healthcare professionals undergo continuous education so they can better identify the different presentations of psoriasis, and patients can be promptly diagnosed. Dr Tan explains, “A lack of awareness among physicians, particularly for the less common forms of psoriasis such as GPP, has historically complicated diagnosis and treatment, leading to delays in appropriate treatment initiation and care.”
To address these challenges, various initiatives have been implemented to raise awareness among healthcare professionals. Thailand’s Dermatological Society conducts frequent educational talks for physicians and general care practitioners. Dr Praneet shares, “When physicians come together for educational sessions either in-person or online, they can bridge gaps in their knowledge about the disease and be better equipped to diagnose and manage different forms of psoriasis effectively.”
Raising awareness about psoriasis is also crucial to reduce stigma and encourage patients to seek treatment without delay. Global initiatives such as World Psoriasis Day, spearheaded by the International Federation of Psoriasis Associations (IFPA), aims to raise awareness and call for action in support of people living with psoriatic disease. It has been celebrated on October 29 for more than a decade and brings together patients, healthcare professionals, and the general public to advocate for better understanding and treatment of psoriasis.
Similarly in Asia, the Psoriasis Association of Singapore (PAS) organizes regular educational public talks which are often complimentary or offered at a nominal fee for patients and caregivers to learn more about the disease.
According to Dr Koh, “Patient education is the cornerstone of effective psoriasis management. Patients need to know that psoriasis is a highly treatable disease and poorly controlled psoriasis increases the risks of other diseases including obesity, hypertension, heart disease, vascular disease, diabetes mellitus, and metabolic syndrome amongst others. Hence, patients must be educated on the need to control modifiable risk factors, which include having a healthy diet, participating in regular exercise, maintaining a healthy weight and stress management.”
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